CME Self-Study Manual: Report for MSSNY Reaccreditation

New York Methodist Hospital CME Program

Self Study Report for

MSSNY Reaccreditation

I. Introduction

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INTRODUCTION

A) Demographic Information

NEW YORK METHODIST HOSPITAL, the applicant, is a large voluntary teaching hospital situated in Park Slope, a prime area of Brooklyn. The hospital was founded in 1880 and has continued to grow. The hospital hosts 640 beds, 80 bassinettes and a whole slew of ambulatory services including extensive clinics in general medicine and general surgery in addition to almost all subspecialties in medicine. The hospital supports 8 fully accredited residency programs in general medicine, surgery, pediatrics, obstetrics and gynecology, anesthesia, radiation oncology and emergency medicine besides several fellowships (e.g. geriatrics, hematology and oncology, pulmonary and critical care and cardiology). It also supports active programs in neurosciences, cardiology and cardiac surgery, neurosurgery, vascular surgery, and surgical oncology.

The hospital has an active medical staff (Medical Board) that is governed by a representative executive committee with a broad based structure of supporting steering committees including a Medical Education Committee, which has established a subcommittee of CME (the CME committee). Practicing physicians form three quarters of the membership of these committees.

All these committees report regularly to the Executive Committee and the full Medical board. There are also several interdisciplinary committees such as the Graduate Medical Education Committee, and Tumor Board. CME is an integral part of almost every committee in the hospital. For example the Quality Improvement Committee identifies various educational needs through its regular monitoring activities, Graduate Medical Education Committee and Medical Education Committee address all CME activities as an essential component for the residency training programs. For scientific boards and re-credentialing CME is part and parcel of their “raison d’etre”

The board of trustees, which governs both hospital management, and the medical board, is the ultimate hospital authority, and receive regular reports of CME Committee.

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A) Application for MSSNY Accreditation or Reaccreditation

Demographic Organizational InformationName of applicant organization as it should appear on accreditation certificate:

1. New York Methodist Hospital2. Chief executive officer of applicant organization:

Name: Mark Mundy Title: President

Address: 506 Sixth Street, Brooklyn, NY 11215

Telephone number: (718)780-3101 Fax number: (718)780-5975

e-mail address: N/A

3. Individual responsible for CME unit :

Name: Stanley Sherbell, MD Title: Executive VP for Medical Affairs

Signature: Date: 04/19/10



e-mail address: [email protected]

4. Individual responsible for survey application materials:

Check here if the contact person is the same as individual responsible for CME unit.

Name: Sameer Rafla, MD, PhD

Title: Chairman Emeritus, Radiation Oncology, Director CME Program



e-mail address: [email protected]

Shipping Method and Account # (for return of materials if necessary)FEDEX - #1768-5497-95. Type of organization (Check the classification which most accurately describes

your organization)

Communications Company School of Medicine

Consortium/ Alliance Not For Profit Foundation (501c3)

Education Company (Physician own/operate)

Specialty Physician Member Organization

Insurance Company/Managed Care Non-Specialty Physician Member Organization

Government or Military Voluntary Health Association

Health Care Delivery System State Medical Society

X Hospital (not-for-profit) Other ______________________ (Specify Type)6. The CME program of the applicant organization (Check all that apply)

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does receive commercial support does produce Journal-based CME

does participate in Joint Sponsorship does produce Internet CME

does produce Enduring Material does produce Point of Care CME

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B) Summary of CME Activities9/1/2008 – 6/30/2009

Name of Organization Contact Person Phone Number

New York Methodist Hospital Sameer Rafla, MD, PhD (718) 780-3677

CME Program Summary

Please provide the following information about your CME activities, indicating N/A if information is not applicable to your organization

Number of

Type of activityActivities

Hours of Instruction

Physician Participants

Non-Physician Participants

Directly sponsored

LiveCourses 5 40 139 38Regularly scheduled series (count each series) as 1 activity)

17 399 5319 622

Performance Improvement (RSS) Includes all 5 M&M with full chart review and responsible MDs, QA case review

5 114 1621 mandated19 relevant mandated ●

Internet N/A Internet Search and Learning N/A

Enduring MaterialsInternet N/A Others N/A

Journal-based CME N/A Subtotal, Directly sponsored

Jointly- sponsoredLive N/A

Courses N/A Regularly scheduled series (count each series) as 1 activity)

N/A Internet N/A Performance Improvement N/AInternet Search and Learning N/A

Enduring MaterialsInternet N/A Others N/A

Journal-based CME N/A Subtotal, Jointly sponsored

Total for all activities 27 553 7077 679

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C)

Attach Hard copy of Activity List 2008-2009 (Excel Document)

(My documents 2008-2009 Reports)

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D) Self Study Report Prologue

D.1. Brief History of CME Program:

This application is for a reaccreditation of a preliminary program that has been active for 2 years located at New York Methodist Hospital. The hospital is seeking reaccreditation by MSSNY as a CME provider. The hospital has a long history of continuing medical activities that cover practically every discipline of medicine. 646 hours of accredited CME activities were offered during the period of September 06 – June 07. Since preliminary accreditation in years 2008 – 2009 sponsored over 1000 hours in 58 programs (enclosure 46). Sponsoring of these CME activities was through present program. The hospital medical community has continued to support CME activities and has contributed significantly to the program ($20,000). The success of the program is encouraging and adding to CME in the institution by increasing the scope of available CME activities and encouraging its physicians to participate avidly has been recognized by the medical board, hospital and board of trustees. In addition, the program created a sense of organization of this important factor and its impact of physician practice and patient outcome. It is important to point out that the structure of various programs are strongly held to physicians needs and possible sources of deficiencies that surface during the various M&M meeting and QI program. There are more than 1200 physicians accredited as members of the hospital medical staff. Over 7000 attendees enjoyed CME sponsored meetings in 2008-2009.

D.2a. Leadership and Structure of CME Program

New York Methodist Mission Statement:The physician community of NEW YORK METHODIST Hospital recognizes that maintaining the medical knowledge and skills necessary to care for patients is a critical ongoing and dynamic process. Educational needs can be expected to develop and change consistent with current evidence based practice and in response to emerging technology, information, and new standards of quality improvement. Our community believes that identifying and organizing an adequate response to these educational needs emanate from a self-imposed will to excel and deliver the best available medical care.

Our purpose is to maintain a program of CME that enables our physicians to achieve this goal.

The community recognizes that during these efforts, professionalism, ethics, and confidentiality (of patients data) are paramount.

The community also aims at fusion of its mission with that of the Hospital, especially as pertains to education, training and creating an environment

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hospitable to intelligent solutions for better patient care and for the benefit of all.We would also consider extending this support to outside educators in other hospitals or medical societies.

The Mission of New York Methodist Hospital, a member of the New York-Presbyterian Healthcare System, is to provide excellent health care services in a compassionate and humane manner to the people who live and work in Brooklyn and its surrounding areas.

In serving its community, the Hospital works to achieve these primary objectives:

To provide excellent health care services which are accessible to patients and physicians without regard to age, sex, race, creed national origin or disability;

To serve as an educational and research center for the training of physicians, nurses and health care professionals committed to the Brooklyn community;

To provide an active ecumenical program of pastoral care and to conduct a clinical pastoral education program;

To offer an environment which is responsive to new and changing technologies and management principles which will stimulate creative solutions for our patients, physicians and employees;

To engage in ongoing assessment of the health care needs of community and to respond to these needs and to work with members of the New York- Presbyterian Healthcare System and other health care institutions, physicians and community grouping in jointly pursuing the delivery of quality health care services, medical education and clinical research.

It is clear that items 2,4 and 5 above is enhanced by CME MissionStatement

The Content of CME programs will be directed at satisfying the needs already identified through various QI steps of the hospital (Enclosure 21). The contents will address practice gaps. The contents will update knowledge and practice of new emerging technologies. Contents will address patient outcome and satisfaction.

Target Audience are primarily the physicians involved in the activity discussed, as well as other physicians who may be involved at a secondary level. Medical students are also accepted as a target audience. Other health professionals such as nurses, physician assistants, and technologists are accepted as audience. However, CME credits are awarded only to physicians. Others will be given letters of attendance. Activities sponsored are symposia, guest lecture series, practice outcome monitoring (M&M), grand rounds, multidiscipline conferences,(eg, Tumor Board,

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NeuroOncology, Radiation Oncology/Rad Path Conference, Pulmonary Conference) and one time conference events that addresses an important topic (eg. The Sickle Cell Bi-Annual Program).

Expected Results of the program include improved physician knowledge and methods of practice, improved physician awareness of new changes in his/her field and other related fields, as well as improved and measured outcome. Data regarding these expected changes will be collected and analyzed on a regular basis using computerization as much as possible to assure timeliness of results of analysis. Results of analysis will be shared with all concerned and used to improve subsequent programs or create new activities.

The CME committee is responsible for approving the mission statement of CME Program.

Committee is composed of:

Members of CME Committee

Name Dept., Title Contact Info.1- Baccash,

Emil MD FACP

Pulmonary Medicine Present President of Medical Tel: (718) 780-5110Staff and P.P. Fax: (718) 780-3222

Email: [email protected] Bharathan,

Thayyullathil MD

Internal Medicine Chief and director of geriatric Tel:(718) 780-5255/50

Geriatricprogram and fellowship chair Fax:(718) 780-3259medical education committee Email: [email protected]

3-Buckner, Cary MD Neurology Practicing Physician Tel: (718) 246-8614/ Caroline 5490

Fax: (718) 246-8656

4- Economos, Katherine MD FACOG

GYN Oncology Practicing Physician & Tel: (718) 780-3090Director of GYN., Oncology Fax: (718) 780-3271

Email: [email protected] Gaeta,

Theodore MD MPH

Emergency Medicine Practicing Physician and Tel:(718) 780-5040 - YesmineChairman research committee Fax: (718) 780-3153

Email: [email protected] Lapidus,

Claudia MDRadiology Radiologist Tel:(718) 780-5870

Practicing PhysicianFax:(718) 780-3494Email: [email protected]

7- Mascatello, Antonio MD

Medicine Practicing physician and Tel:(718) 833-5273 (outside)

Past President of Medical Staff Email: [email protected] 8- Mir, Rabia

MDPathology Pathologist, Tel:(718) 780-3634


9- Narula, Pramod MD

Pediatrics Chairman and Tel:(718) 780-5260Practicing Physician Fax:(718) 780-3266

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Email: [email protected] Rafla,

Sameer MDRadiation Oncology Chairman and Tel: (718) 780-3677

Practicing PhysicianFax: (718) 780-3637Email: [email protected]

Rucinski, James, MD General Surgery Deputy program director for Tel: (718) 780-3288

Program of Surgery and P.P. Fax: (718) 780-3154Email: [email protected]

12- Salama, SalamaMD

Pulmonary Medicine Practicing Physician Tel: Fax: (718) 621-7103Email: None (outside)

13- Salgado, Miran MD

Neurology Practicing Physician and Tel: (718) 246-8614Chair of Neurological Sciences Fax: (718) 246-8656

Email: [email protected] Sherbell,

Stanley MDPulmonary Medicine Executive V.P. for Medical Affairs Tel: (718) 780-3284

Fax: (718) 780-3287Email: [email protected]

15- Schifter, David MD

Int., Medicine Cardiology Cardiology, Past President, Tel: (718) 499-5300 (outside)Medical Board, Practicing Physician Fax: (718) 499-6161

Email: does not have16- Simon, Todd

MDInternal Medicine Vice Chairman Dept., of Medicine Tel: (718) 780-5251


17- Vardi, Joseph MD

OB/GYN Practicing Physician Tel: (718) 871-3737Fax: (718) 871-4595Email: call Annete

18- Yarmush, Joel MD

Anesthesiology Vice Chairman and Tel: {718) 780-3279


19- Zonenshayn, Martin MD

Neuro-surgery Practicing Physician Tel: (718) 246-8610Fax:(718) 246-8611Email: [email protected]

Committee is Chaired by Sameer Rafla, MD, PhD, CME Program Director. Committee minutes become part of Medical Education Committee Minutes → Board of Trustees after Executive Committee reviews

Mission Statement is reviewed regularly. Last review November 2009.

Date: January 2010

D.2.a. Links between CME mission and organization mission:

The CME mission includes the identification, development and promotion of quality CME (CME) utilized by physicians in their maintenance of competence as well as incorporation of new knowledge aimed at improving quality care for patients in the

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community. NY Methodist Hospital considers medical education, both graduate medical education and CME of their physicians (and other health professionals) as an essential component of its mission. The institution believes that keeping its physicians (and all its health professionals) abreast of recent medical and scientific development is an integral component of quality medical care.

We calculated that the hospital sponsors over 26 hours of medical education everyday, most of that comes under the purvue of CME.

There is a strong link between CME and continuing accreditation.

D.2.b. CME Program strength:

We believe that our proposed program enjoys the following points of strength and distinction:

i. Commitment of the hospital medical staff as represented by the medical board leadership. All physicians at NY Methodist are members of the medical board. A president is elected every year as well as an executive committee.

Enclosure 3 is a letter from the president of the medical staff and expressing strong support of the program and the financial support for that year. We have in our records over 500 signed copies of letter of support submitted by physicians from all disciplines. Over 14,000 physician attendees frequent various CME activities since provisional approval. There is a widespread of support of the program among hospital physician community.

Another evidence of support of the medical staff is the strong financial support extended to the program by a significant yearly contribution towards the expenses of the program.

ii. Commitment of hospital management to the program is evident and their investment in the program is substantial. The CME office of NY Methodist is part of the office of the Senior Vice President of Medical Affairs who has the overarching management responsibility of the program (page 25). There are full time staff members who are managing the program. In addition, the hospital has supported full computerization of the program allowing digital scanning of attendees, evaluations and generation of various reports. Since approval, CME reports become a

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required component of these deliberations of GMEC, the medical education committee and the executive committee of the medical board.

iii. Commitment of leadership of CME Committee: A review of the membership of the CME committee with its complements of academic physicians, practicing physicians and administrators physicians, (all volunteers) reveals a commitment of the institution as a whole and each member individually. Included in Enclosure #3 are letters from committee members assuring their enthusiastic support for the CME mission and its objectives. It must be noted that committee membership have full representation from the various institutional medical communities, namely the medical board (all the medical staff), clinical chairmen and section chiefs, program directors, practicing physicians and medical administration. Each group has a special interest in maintaining an active CME program in order to maintain a cadre of physicians whose knowledge and expertise is continuously updated to assure best patient care and the maintenance of quality practices in the face of market place competition.

iv. Commitment of graduate program leadership to the program:Graduate programs (residencies) leadership are strongly supportive of CME program as it certainly adds to the knowledge and skills of their graduates who continue to practice in the institution.

The requirement of the various medical boards for re-certifications has required CME activities to rise to an organized approach rather than patchy programs.

Graduate program leadership view CME as a necessary extension of their programs in the “afterlife”.

v. Availability of funds and continuing support:As will be seen in part 4 under administration, both hospital management and medical board are supportive of the program. The hospital is committed to support the operational costs (personnel, computerization…. etc.) as well as the maintenance of the program. Medical staff organization is committed to a significant annual contribution towards the program. Enclosure 8 is a copy of communication from the President of the medical staff to that effect.

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vi. Availability of space: The hospital has over 15000 square feet allocated for educational and scholarly activities with an attractive auditorium that seats 120 participants and equipped with full state of the art electronic audiovisual tools including an audience response system.

vii. A New York Methodist Hospital CME authority will increase the availability of CME programs to other physician communities in Brooklyn.

viii. All CME activities are electronically displayed and updated weekly in the doctors’ lounge.

D.2.c. Areas for Improvement and Plans for Addressing

Through our experience with the program so far we plan to develop it to achieve the following objectives:

1. Making CME credits acquisition mandatory for physicians’ reaccreditation.

2. Purifying the CME by requiring that > 70% of the credits is obtained either through our program or programs offered by professional societies or academic centers. That will limit commercially sponsored CME credits to less than 30% of required credits.

3. Link CME credits to identifiable points in physician performance and patient outcome. Several networks may be utilized; the simplest could be upgrading the credit points offered by certain programs.

4. Creating stronger links between CME programs and community needs identified in public local media and ER, OP surveys, as well as other venues such as community board.

5. CME will conduct an institution wide activity to which all present or potential program directors are invited to alert them to updated accreditation requirements especially all the evaluation activities with attention to measuring outcome and impact.

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E. Monitoring System of RSS for ComplianceNew York Methodist CME Program reviews and accredits several RSS.

E.1. Sampling and Monitoring MethodsCME Program at New York Methodist Hospital conducts an extensive monitoring system that starts at point of conception, carried through implementation and participant evaluation, as well as unannounced site visits by CME representatives and early actions on monitor reports. Monitor reports, program directors final reports as well as specifics of application for program renewal are examined carefully for compliance with the guidelines:

1. Planning Stage:a. A member of the CME Committee must be included in the

planning committee (see Enclosure 10)b. Assessment of educational needs and how was this

developedc. The objective of the program must be clearly indicated and

linked to needs d. The venue chosen by the program is monitored to verify

educational needs are met (eg audiovisual, space, access, etc.)

2. Application Form:Is monitored for compliance, as well as all the attached documents of activity agreement. Close attention is paid to possible commercial support (clarity, detailed budget, disclosure forms, brochures, etc…(See Enclosure 11 for an example).All the above-steps are reviewed by the Steering Committee if there is a positive recommendation from staff; Steering Committee applies its own monitoring steps.

3. Implementation Phase:Several monitoring steps are in place:a. Attendance is monitored by card swiping in a computerized

terminal. All cards are regularly monitored for accuracy and relevance. Cards are collected at end of meeting to prevent tampering.

b. Data of attendance are monitored and analyzed and reported at end of program.

c. Evaluation forms are completed by attendees (Enclosure 12)

d. Evaluation forms are monitored along with attendance data. Evaluations are computerized and analyzed (Enclosure13) by Steering Committee. We also plan to conduct a

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midterm evaluation analysis, if the need arises e.g. monitoring step reveals a significant regularity.

e. An unannounced site visitor attends a meeting to monitor it, complete a special form (Enclosure 14) and submit a report if a major deviation is noted. Such reports are addressed immediately and a remedial action is taken. We have had to withdraw CME credit from a particular meeting that was found non-compliant (example Enclosure 15). Educators, hospital-wide, have been warned that a repetition of such infraction will result in denial of CME accreditation to whole program.

f. The final report about the activity is monitored to assure its compliance with the numbers on the ground (eg. Number of attendees, degree of program success in achieving its objectives, impact of program or physician skills and impact of program on practice modification.)

All the above data are reported directly to the CME Steering Committee and CME Committee for input. The final reports are submitted to the Executive Committee of Medical Board via the Medical Education Committee. All these recommendations are eventually submitted to the Board of Trustees.

E.2 Accreditation Requirements Monitored

With a focus on RSS, NEW YORK METHODIST CME Program monitors the following accreditation requirement in programs it approves.

E.2.1Educational needs are identified by various departments or multidisciplinary groups (eg, Tumor Board) based on identified gaps in knowledge of physicians (eg, related to new technology or new important finding), progress in the particular discipline, which has identified new standards of practice, changes in the requirements of regulatory agencies vis-à-vis infection control or child abuse or radiation protection, etc., alerts from CDC or Department of Health regarding an existing or impending problem.

E.2.2Objectives of the program must meet the mission of CME vis-à-vis the content, target audience, and expected result. The type of program is also important eg. M&M Program must target or identify gaps of practice and remedies of these gaps. (See Enclosure 16). Equally important new technical services, for example, must focus on technologies and not products (See Enclosure 17)

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E.2.3Learner Change Data are collected and analyzed regularly. Feedback is submitted to program directors for future planning (Enclosure 18). In some programs, we have succeeded in implementing some written questions on the topic discussed before and after the meeting to gauge the scope of change (Enclosure 19).

E.2.4Patient outcomes and its relations to a particular education program is difficult to match due to the many confounding factors in patient outcome. However, we are able to monitor outcome through constant observation of M&M and adverse events reported in a particular department. Any repetition of poor patient outcome raises a red flag and creates an opportunity for an in-training educational activity, some of those go through the CME program but others may be instituted almost immediately depending on the urgency of the situation.

E.2.5Of 2,958 evaluations analyzed, over 87% of physicians indicated they learned new data and over 71% indicated that this will impact their practice (Enclosure 20) shows a limited sample of evaluations analysis by program during the period of January – June 2009. Analysis of different components of evaluations program namely consisting of objectives with CME program, content, participation of attendees, changes in competence and outcome is ongoing. The sample size now allows relevant statistical analysis.

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F) Organization’s Change Process

F.1We intend to update our application forms to incorporate the new accreditation data especially those pertinent to monitoring the identification of needs, planning of the program with objectives that meet the needs, parameters to measure the effectiveness of the program.

F.2We will conduct a survey of all attendees of each program at the end of the program to monitor their possible gain in knowledge and change in practice.

F.3We will observe the rate of success of various physicians in receiving their board certification. After all, a large part of new information, which are the subject of recertification exam come through the CME Program of the hospital. It must be acknowledged, however, that other CME Programs may have also contributed to this.

F.4Approach the Medical Executive Committee, management and Board of Trustees to take steps that would highlight the relevance of the CME activities. Upgrading CME to a hospital department may be useful.

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G. Annual Report

CME Program

2008 – 2009 ANNUAL REPORT

CME Mission Statement:The physician community of NEW YORK METHODIST Hospital recognizes that maintaining the medical knowledge and skills necessary to care for patients is a critical ongoing and dynamic process. Educational needs can be expected to develop and change consistent with current evidence based practice and in response to emerging technology, information, and new standards of quality improvement. Our community believes that identifying and organizing an adequate response to these educational needs emanate from a self-imposed will to excel and deliver the best available medical care. Our mission is to maintain a program of CME that enables our physicians to achieve this goal.

The community recognizes that during these efforts, professionalism, ethics, and confidentiality (of patients data) are paramount. The community also aims at fusion of its mission with that of the Hospital, especially as pertains to education, training and creating an environment hospitable to intelligent solutions for better patient care and for the benefit of all.

We would also consider extending this support to outside educators in other hospitals or medical societies.

CME Steering Committee at New York Methodist met at least six times for the 2008 – 2009 academic year. The committee addressed various issues from the implementation of the CME program to the distribution and cost of certificates to participants.

The card scan-swipe system “eeds” had been used to monitor and document the attendance for each participant in all programs. An ACCME report is attached, which reflects the hours of instruction, physician attendance, non-physician attendance and total for all regularly scheduled series, as well as one-time conference events. (Attached)

For accurate reporting and rating of each program standard electronic evaluations were developed (January 2009) using a standard format (copy enclosed) and the “Scantron System”. Cumulative count and percent reports were generated to tabulate responses from participants. All reports were issued to program directors for assessment and review of the outcome of their program. Program directors were given the opportunity to consider the outcome evaluation results in the design of their new programs as necessary.

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We have, repeatedly, stressed the importance of completing evaluations by all attendees in order to ensure the accuracy and relevance of the evaluations.

It is estimated that approximately 11% of CME costs had been received from commercial industry or other “outside” financial sources. Unrestricted commercial grants amounted to $35,000. The total cost of various programs offered by the hospital exceeds $300,000/year. The administrative cost amounts to about $35,000/year.

According to results of program evaluations submitted and tabulated, which addressed the effectiveness of the speaker, topics presented, time allowed, objectives of activity, opportunity for discussion and venue satisfaction, an estimated 91% of participants maintain and gained the educational needs, medical knowledge and skills necessary to care for patients at New York Methodist.

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Report of

CME Activities for the Year 2009

Submitted by:Dr. Sameer Rafla, Director CME Program

Our first year as a CME accreditation provider has been very productive. The attached tables demonstrate a snapshot of the program:

Total number of programs: 27 Number of Sponsors (Program Directors) 22 Total number of physician attendees: 7077

All the programs seemed to have complied with program requirements.

The evaluation program consists of 2 parts:1. A summary of the evaluation forms completed by the attendees and analyzed

by an E-Listen for each program. Report is assembled on a monthly basis (an example is included. A full one-year overview is being generated and will be submitted in next meeting).

2. A report from each sponsor about the program they conducted.

The satisfaction with various programs has been on the whole very laudatory. The reports from various sponsors are yet to be completed. These will be summarized and submitted to you as soon as possible.

MSSNY, the parent authority for accreditation, has strongly suggested a close monitoring of the programs we accredit. Towards that end, a proposal of a monitoring system will be submitted to the next meeting of CME Committees, scheduled February 18, 2010.

We are in continuing communication with MSSNY who hold a monthly telephone conference for monitoring and update.

We are in the process of completing application for accreditation according to following timetable.

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II. Essential Area 1: Purpose and Mission (Criterion 1)

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Essential Area 1: Purpose and MissionA. CME Mission Statement:

The physician community of NEW YORK METHODIST Hospital recognizes that maintaining the medical knowledge and skills necessary to care for patients is a critical ongoing and dynamic process. Educational needs can be expected to develop and change consistent with current evidence based practice and in response to emerging technology, information, and new standards of quality improvement. Our community believes that identifying and organizing an adequate response to these educational needs emanate from a self-imposed will to excel and deliver the best available medical care. Our mission is to maintain a program of CME that enables our physicians to achieve this goal.

The community recognizes that during these efforts, professionalism, ethics, and confidentiality (of patients data) are paramount. The community also aims at fusion of its mission with that of the Hospital, especially as pertains to education, training and creating an environment hospitable to intelligent solutions for better patient care and for the benefit of all.

We would also consider extending this support to outside educators in other hospitals or medical societies.

The Content of CME programs will be directed at satisfying the needs already identified through various QI steps of the hospital (Enclosure 21). The contents will address practice gaps. The contents will update knowledge and practice of new emerging technologies. Contents will address patient outcome and satisfaction.

Target Audience are primarily the physicians involved in the activity discussed, as well as other physicians who may be involved at a secondary level. Medical students are also accepted as a target audience. Other health professionals such as nurses, physician assistants, and technologists are accepted as audience. However, CME credits are awarded only to physicians. Others will be given letters of attendance.

Types of Activities: Activities sponsored are symposia, guest lecture series, practice outcome monitoring (M&M), grand rounds, multidiscipline conferences,(eg, Tumor Board, NeuroOncology, Radiation Oncology/Rad Path Conference, Pulmonary Conference) and one time conference events that addresses an important topic (eg. The Sickle Cell Annual Program).

Expected Results of the program include improved physician knowledge and methods of practice, improved physician awareness of new changes in his/her field and other related fields, as well as improved and measured outcome. Data regarding these expected changes will be collected and analyzed on a regular basis using computerization as much as possible to assure timeliness of results of analysis. Results of analysis will be shared with all concerned and used to improve subsequent programs or create new activities.

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The CME Steering Committee is responsible for approving the mission statement of the program. Reports of Steering Committee are ratified by CME full committee.

Mission Statement was last reviewed in November 2009. (See Enclosure 45)

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ORGANIZATIONAL FRAMEWORK AND CHART

ADD

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Name Dept., Title Contact Info.1- Baccash, Emil

MD FACPPulmonary Medicine Present President of Medical Tel: (718) 780-5110

Staff and P.P. Fax: (718) 780-3222Email: [email protected]

2- Bharathan, Thayyullathil MD




Fax: (718) 246-8656



Email: [email protected] Gaeta, Theodore

MD MPHEmergency Medicine Practicing Physician and Tel:(718) 780-5040 - Yesmine

Chairman research committee Fax: (718) 780-3153Email: [email protected]

6- Lapidus, Claudia MD

Radiology Radiologist Tel:(718) 780-5870




Past President of Medical Staff Email: [email protected] 8- Mir, Rabia MD Pathology Pathologist, Tel:(718) 780-3634



Pediatrics Chairman and Tel:(718) 780-5260


10- Rafla, Sameer MD

Radiation Oncology Chairman and Tel: (718) 780-3677


11- Rucinski, JamesMD

General Surgery Deputy program director for Tel: (718) 780-3288Program of Surgery and P.P. Fax: (718) 780-3154

Email: [email protected] Salama,

SalamaMDPulmonary Medicine Practicing Physician Tel:

Fax: (718) 621-7103Email: None (outside)



Email: [email protected] Sherbell, Stanley

MDPulmonary Medicine Executive V.P. for Medical Affairs Tel: (718) 780-3284


15- Schifter, David MD

Int., Medicine Cardiology Cardiology, Past President, Tel: (718) 499-5300 (outside)Medical Board, Practicing Physician Fax: (718) 499-6161

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Email: does not have16- Simon, Todd

MDInternal Medicine Vice Chairman Dept., of Medicine Tel: (718) 780-5251




18- Yarmush, Joel MD

Anesthesiology Vice Chairman and Tel: {718) 780-3279



Neuro-surgery Practicing Physician Tel: (718) 246-8610

Fax:(718) 246-8611Email: [email protected]

Committee is chaired by S. Rafla, CME Program Director. Committee minutes become part of Medical Education Committee minutes → Board of Trustees after Executive Committee reviews

CME Steering Committee Members:

Sameer Rafla, MD. PhD

Chairman Emeritus, Radiation OncologyDirector, CME Program

Stanley Sherbell, MDExecutive Vice President for Medical Affairs

Thayyullathil Bharathan, MDVice Chairman Department of Medicine Associate Program Director

Todd Simon, MDVice Chairman Department of Medicine Associate Program Director

Antonio Mascatello, MDInternist, Department of Medicine

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III. Essential Area 2: Educational Planning (Criteria 2-3)

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2.A. Element 2.1:

Planning Process:

1. Needs evaluation and assessment: gap definition

Each department and section in the hospital has a mandated quality review and improvement committee in addition to an institution wide quality improvement committee (enclosure 1) as well as various AD HOC quality improvement committees that are continuously created as pertinent issues of health care arise. Examples of standing committees in internal medicine are: general medicine, pulmonary critical care medicine, cardiology, oncology-hematology, gastroenterology, infectious disease, geriatric medicine, AD HOC committees in that department during the year of 2006, amounted to 3. Enclosure 1 represents samples of such meetings.

It is estimated that there are about 50 different quality program committees and subcommittees that were active at NEW YORK METHODISTH during the last 12 months.

The corrective action steps for issues that arise out of these extensive activities start with an educational effort. Various clinical leaders in the hospital regularly mount educational programs (e.g. a symposia, a lecture or a workshops) that are organized as part of an institution wide effort to respond to these needs. Most of these efforts constitute CME.

The academic programs, by their nature, are continuously mounting educational programs directed at their faculty, practicing physicians and physicians in training. Among the main features of many of these programs is the CME credit attached to worthy programs. That need drives several CME activities. In addition, the continuing process of credentialing and re-credentialing for all hospital physicians requires the acquisition of a minimum of 50 hours of CME credits every 2 years. The need associated with this requirement is self-evident.

The evolution of many new procedures in various disciplines and the need to make these procedures available to hospital patients creates a recurring requirement for CME programs. An example of a recent such effort was introduction of partial breast irradiation as part of organ sparing technology for treating breast cancer. An interdisciplinary (surgery, radiation oncology, radiology, pathology, physics) symposium was mounted which constituted the basis for credentialing physicians who perform the procedures as well as the larger group of physicians who recommend it for their patients. (Enclosure 3)

2. Planning Process:

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As a need arises that requires a CME intervention in any of its various forms (a lecture, a visiting professor activity, or symposium), the following planning steps occur:

1. Interested parties are required to form a program committee with definable leadership (enclosure 22 shows minutes of such committee along with a member of CME and identifiable chair.

2. Program committee approaches CME office for possible award of CME credit, a preliminary application submitted (enclosure 11) and a planning meeting is held where CME office is represented. Four elements must be discussed during that meeting and data completed on a computerized form that addresses, objectives, audience targeted, program outline and evaluation methods. As this step is satisfied program is considered Preliminary.

3. “Preliminary” program is reviewed by the CME Steering Committee (which meet every month) for advice and consent.P.S. In special circumstances, (e.g. an urgent event that requires rapid approval) a preliminary review is conducted by the CME program coordinator who advises the steering committee as soon as possible.

Preliminary program is reviewed for:

a. Feasibility (timing, planned space, planned budget, required resources)b. Appropriateness (objectives and evidence).c. Budget review (grants, commercial support, etc…) and financial

disclosures.d. Evaluation method

4. Advice is conveyed to program committee which schedules a final working meeting with participation of CME where: Objectives, target audience, program outline are finalized. Speakers are identified. Meeting details discussed and finalized. Budget finalized Request for CME accredited hours is submitted according to computerized

format along with financial disclosures.

5. CME steering committee examines the submission and evaluates program plan vis-à-vis the same 4 items listed under item 3. In the addition the draft of the brochure is submitted and examined.Decision regarding tentative approval and number of credit hours awarded is made pending the final copy of brochure. Letter of agreement signed (enclosure 36)

6. As soon as brochure is finalized the CME approval is formalized pending evaluation of audience and program evaluation.

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2.B. Enclosure 3 shows activities, which were generated based on specific identified needs.

2.C. The example we chose to demonstrate CME activity designed to change competence and performance is the symposium program of radiation oncology (Enclosure 27). All update items are designed to add competence and improve performance. As an example the update given by Dr. Ashamalla about Stereotactic body Radiosurgery was planned and implement to achieve that. The Department of Radiation Oncology moved to add this method of cancer treatment following this activity.

The objectives of each CME activity are built in the program announcement. Enclosure 39 is an example of method of conveying objectives of CME. This component is mandatory in each program. It is also included in a special electronic announcement board located in the doctor’s lounge, which announces all the CME activities of the day classified according to sponsoring discipline.

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IV. Essential Area 2: Education and Planning (Criteria 4-6)

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Essential Area 2

A. See attached examples (Enclosures 23 & 39), one for Radiation Oncology (RSS) and the other for Medicine (Single event program). All topics chosen are pertinent to the learner’s current or potential scope of practice whether it is Radiation Oncology, which concerns itself with all aspects of cancer, epidemiology and management including quality of life issues. Aspects of of practice in sickle cell disease are addressed in example 2 in great detail.

Programs are monitored at its inception, during its implementation (Enclosures 25 & 26). Learners evaluations are also obtained when appropriate learner’s were subjected to questions, before and after the activity to gauge the scope of benefit (Enclosure 19).

B. Educational formats used in our programs are:a. Symposiab. Guest lecture seriesc. Grand Roundsd. One issue eventse. Coursesf. Multidisciplinary

C. The two examples used are:1. One issue event: The Sickle Cell Program

The program is designed to meet the demonstrated needs surrounding this important disease.

The Program contents upgrade the learner’s information about aspects of this disease.

The format had been used successfully before for this disease. The hospital serves a large population at risk for this disease making

the program relevant. The program director is a recognized leader in her field.

2. An example of RSS is the Radiation Oncology Resident Symposium (Enclosure 27) We have demonstrated the appropriateness of objectives of this

program. We have demonstrated that the program meets the requirements of the

scope of practice of patients. We have demonstrated that the continuing evaluation of the program

format assures the participation of the learners (presenters and discussants), participation of educators (various contents for completion and appropriateness), as well as a detailed evaluation of outcome.

The program is planned during a whole day retreat meeting (Enclosure 28)

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D. In the examples we used, the attributes examined were the successful completion of the Certification for the American Board of Radiation Oncology for new physicians and Continuing Certification for practicing physicians.

All our physicians, new or practicing, have acquired the desired attributes.Similar attributes for the surgical or medical programs were also examined. Success among their new physicians is high, e.g. 100/in medicine. All surgeons who sought recertification were successful. In addition, the content of both these programs were examined vis-à-vis the requirements for the attributes and all were found applicable.

In the examples used, we have demonstrated the participation of all physicians involved either by presenting, discussing, generating written questions, correcting and discussing answers.

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V. Essential Area 2: Educational Planning (Criterion 7:

Standards for Commercial Support – Independence)

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Essential Area 2 – Commercial SupportA. See Enclosure 29 for standing guidelines when a commercial support exists.

Commercial support for our program is sparse and only few programs receive any commercial support.All decisions related to identification of needs, educational objectives, content and personnel who control it, as well as the program design and evaluation of activity are under the exclusive control of the program director. The CME director, staff, steering committee and CME committee keep a sharp eye for any infraction.

B. We have had no joint sponsorship relationship. The only arrangement we accept is an educational grant without strings attached.

C. Enclosure 30 is a disclosure statement. Refusals are disqualified.D. Our standing guidelines address conflict of interest issues (Enclosure 31)E. Our standing guidelines mandate that participants demonstrate thisF. All those who are accepted to lead a program and control its contents, are required

to disclose relevant financial relationships according to our guidelines. (Enclosure 31 & 32)

G. New York Methodist has a policy of assuring non-conflict of interests (Enclosure 31) of the institution and its staff. This is a pre-requisite.

H. Monitoring System of RSS for ComplianceNew York Methodist CME Program reviews and accredits several RSS.

H.1. Sampling and Monitoring MethodsCME Program at New York Methodist Hospital conducts an extensive monitoring system that starts at point of conception, carried through implementation and participant evaluation, as well as unannounced site visits by CME representatives and early actions on monitor reports. Monitor reports, program directors final reports as well as specifics of application for program renewal are examined carefully for compliance with the guidelines:

1. Planning Stage:e. A member of the CME Committee must be included in the

planning committee (see Enclosure 10)f. Assessment of educational needs and how was this

developedg. The objective of the program must be clearly indicated and

linked to needs h. The venue chosen by the program is monitored to verify

educational needs are met (eg audiovisual, space, access, etc.)

2. Application Form:Is monitored for compliance, as well as all the attached documents of activity agreement. Close attention is paid to possible

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commercial support (clarity, detailed budget, disclosure forms, brochures, etc…(See Enclosure 11 for an example).All the above-steps are reviewed by the Steering Committee if there is a positive recommendation from staff; Steering Committee applies its own monitoring steps.

3. Implementation Phase:Several monitoring steps are in place:a. Attendance by card swiping in a computerized terminal.

All cards are regularly monitored for accessory and relevance. Cards are collected at end of meeting to prevent tampering.

b. Data of attendance are monitored and analyzed and reported at end of program.

c. Evaluation forms are completed by attendees (Enclosure 12)

d. Evaluation forms are monitored along with attendance data. Evaluations are computerized and analyzed (Enclosure13) by Steering Committee. We also plan to conduct a midterm evaluation analysis.

e. An unannounced site visitor attends a meeting to monitor it, complete a special form (Enclosure 14) and submit a report if a major deviation is noted. Such reports are addressed immediately and a remedial action is taken. We have had to withdraw CME credit from a particular meeting that was found non-compliant (example Enclosure 15). Educators, hospital-wide, have been warned that a repetition of such infraction will result in denial of CME accreditation to whole program.

f. The final report about the activity is monitored to assure its compliance with the numbers on the ground (eg. Number of attendees, degree of program success in achieving its objectives, impact of program or physician skills and impact of program on practice modification.)

All the above data are reported directly to the CME Steering Committee and CME Committee for input. The final reports are submitted to the Executive Committee of Medical Board via the Medical Education Committee. All these recommendations are eventually submitted to the Board of Trustees.

H.2 Accreditation Requirements Monitored

With a focus on RSS, NEW YORK METHODIST CME Program monitors the following accreditation requirement in programs it approves.

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H.2.1Educational needs are identified by various departments or multidisciplinary groups (eg, Tumor Board) based on identified gaps in knowledge of physicians (eg, related to new technology or new important finding), progress in the particular discipline, which has identified new standards of practice, changes in the requirements of regulatory agencies vis-à-vis infection control or child abuse or radiation protection, etc., alerts from CDC or Department of Health regarding an existing or impending problem.

H.2.2Objectives of the program must meet the mission of CME vis-à-vis the content, target audience, and expected result. The type of program is also important eg. M&M Program must target or identify gaps of practice and remedies of these gaps. (See Enclosure 16). Equally important new technical services, for example, must focus on technologies and not products (See Enclosure 17)

H.2.3Learner Change Data are collected and analyzed regularly. Feedback is submitted to program directors for future planning (Enclosure 18). In some programs, we have succeeded in implementing some written questions on the topic discussed before and after the meeting to gauge the scope of change (Enclosure 19).

H.2.4Patient outcomes and its relations to a particular education program is difficult to match due to the many confounding factors in patient outcome. However, we are able to monitor outcome through constant observation of M&M and adverse events reported in a particular department. Any repetition of poor patient outcome raises a red flag and creates an opportunity for an in-training educational activity, some of those go through the CME program but others may be instituted almost immediately depending on the urgency of the situation.

H.2.5Enclosure 20 shows a sample of early and limited evaluation analysis of 2958 evaluations 87 % of physicians indicated they learned new data and 71% indicated that this will impact their practice. Complete and detailed analysis of different components of the program (content, attendees participation, competence and outcome is ongoing. Enclosure 20B shows an example of one program detailed analysis.

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VI. Essential Area 2: Education and Planning (Criterion 8: Standard for Commercial Support – Management

of Funds

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Our policy and procedures addresses the issue of sources of funds. They also address the issues of honoraria, planers, disclosures, etc. Follows are pertinent data requested.

Speakers are paid an honorarium consistent with prevailing academic standards and their standing in the discipline and written agreements with them reached before conference planning is completed.

In-house speakers honoraria are subject to same rules. Planners, whether in-house or outside consultants are paid a fee dependent on the extent of services they provide, expected number of attendees, complexity of arrangements (eg, overseas speakers) and length of the conference. The market reputation of the planner is also an important factor. A written agreement signed by a legal representative of the outside planner and a hospital senior manager (VP for Medical Affairs) and program director is completed before the planners can start their activities. To summarize:

A. Hospital planners are allowed a fee consistent with the time they spend on this task, prorated to their hourly income.

B. Teachers, speakers, authors are paid an honoraria compatible with their rules and contribution to the activity they participate in.

C. Any durable material, which may be supplied, is reviewed by the program director to assure compliance with SCS 2.7, 3.10. This material will be forwarded to CME program before the activity, if available, or with the final report of the activity. CME will review material for compliance. Infraction of guidelines may result in denial of CME credits even if the conference receives prior approval. However, this remedy is only applied in extreme cases of intentional and callous disregard of guidelines, since it may also penalize attendees who may not have played a role in the infraction.

D. All funds are received as unrestricted grants and they are deposited in hospital specific accounts. No restricted or conditioned grant is accepted for a CME program. All expenses are disbursed by hospital finance directly to the recipients based on a special check request, approved by program director and the chairman of the department sponsoring the activity. These check requests are usually reviewed by the higher echelon of hospital management (Vice President) before approval. The grantor of any commercial support does not play a role in planning the activity, its conduct or contents.

E. A review of point D shows that:a. Commercial support is given with full knowledge of the hospital

(Enclosure 33)b. Funds disbursed to honoraria, planners or other items are disbursed from

hospital finance after full review and approval of management.(Enclosures 33 demonstrate the system implementation).

F. All programs are required to submit a final report of the activity including disbursement of funds. Enclosure 34 shows final disbursement of funds in 2 programs to very adherence to guidelines.

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G. A review of the program brochure (2 examples attached – Enclosure 35) shows that only minimal social events are planned, essentially coffee and lunch breaks.

H. Enclosure 36 shows 2 examples of a written agreement documenting terms, conditions and purposes of commercial support used to fulfill relevant elements of SCS 3.4-36

I. Our program does not produce hard copies as a routine. For post script hard copies of materials see Enclosure 37.

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VII. Essential Area 2: Educational Planning (Criteria 9-10) Standards for

Commercial Support-Separation of Education from Promotion, Promotion of

Improvements in Healthcare

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Essential Area 2 – Separation of Education from Presentation

A. New York Methodist CME does not organize commercial exhibits. Only scientific papers can be posted during appropriate conferences.

B. No advertisements are accepted during CME conferences. We only have a poster that discloses the name of supporters.

C. All hard copy materials (slides, handouts, abstracts) are received before hand, if available; to ensure that there is no adversity or trade names. Material submitted postscript is subject to same scrutiny. Violators, if any, are sternly dealt with. Enclosure37 represents an example of handouts.

D. Commercial interest does not play a recognizable role in access to CME activities for learners. Brochures and information about meetings are supplied and distributed free to all potential learners.

E. Several monitoring steps are used to ensure that CME activities are not utilized to promote commercial interest. Those include review and approval of the content, speakers, venues, and deliverables – if any – brochures, budget and final report.Program participants sign a CME agreement denoting their abiding by the rules (Enclosure 38)In addition, the presence of 2 representatives of CME on program committee will ensure compliance with the standard of balanced approach (Enclosure 10 and 39). Also, there are enough members on the planning committee to assure a balanced approach (Enclosure 39). Besides the balanced value of the content, its validity is judged by the reviewing committees. We expect the program director to watch and report on the content validity such as studies quoted, graphs displayed and statistics used. In addition, all attendees are asked to report on content in questions 3 and 4 of Enclosure 41.

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VIII. Essential Area 3: Evaluation and Improvement (Criteria 11-15)

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VIII Evaluation and ImprovementA. Enclosure 40 is a general report of evaluation of activities attendees. Of

about 3000 evaluations completed, a significant number said that the activity has added new information to their knowledge, reported new clinical skills and went as far as making changes in their practiced based on the information they had. Reporting and counting in our system is all electronic.Enclosure 41 is the evaluation format.

B&C. Enclosures 40, 41 & 42 show the forms used in daily monitoring of all programs. Attendance is electronically recorded. Evaluation is electronically recorded by program and date of activity (to allow determination of service of problems if any occurs). Analysis is a computer generated report – Enclosure 40 and 20B.

D. Conclusions based on analytical data, site visits, program reports to CGME meetings follows:

1. The program reaches its target audience in all occasions, 100% as reported by site visitors, see Enclosure 25 & 26.

2. Over 80% of respondents to questionnaire believe that the content was highly appropriate.

3. Over 90% of attendees reported that enough time was allowed for a give and take.

4. About 72% reported learning new skills and a similar proportion reported intent to make changes in clinical practice

These figures represent an average across various programs. An analysis of 62 evaluations of Surgery M&M in 03/10, shows better results. There is certainly an improving trend but we are analyzing a larger sample to confirm the results.

E.1. The manner and degree to which New York Methodist Hospital integrated CME into the process of improving professional practice helped to enhance the hospital’s success in meeting its CME mission is demonstrated through the reach of the program (to the bulk of attending physicians), the relevance of the programs contents to the objectives of the CME, the stress of the importance of CME that evaluations (which are generally distributed at meeting end) are completed by a significant number of attendees, the inclusion of the standard format of evaluation reduced possibilities of misunderstanding and allowed relevant evaluation of CME activity.

E.2. Non-educational strategies used by NEW YORK METHODIST to enhance change (e.g. wide introduction of computerizing facilities and PACK systems) helped NEW YORK METHODIST to meet a substantial component of CME activities missions such as relevant presentations, abilities to conduct and analyze evaluations and improvement in patient care outcome.

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E.3. A review of the subsequent section shows examples of factors outside our control that impact patient outcomes. Identification of deficiencies such as limited institutional funds dedicated to CME activity helped us to plan CME activities that require less expenses eg. depending on in-house available audio-visual means. However, using a deficiency outside one’s content to create an opportunity for improvement is very challenging.

E.4. Barriers to physician change are many. New York Methodist employed and implemented several educational and training strategies to overcome that e.g. Errors in medication prescription, dosage and timing were overcame by the introduction of computerized pharmacy orders where physicians were trained using hands-on tutorials. Another example is the use of PACK system to allow physicians accurate and early access to imaging of their patients allowing faster and more accurate changes in patient outcome. Training physicians on computer skills utilized hand-on workshops and several on-site trainers. None of these activities were CME accredited although they are educational in objectives and implementation with a recognized outcome.

E.5. New York Methodist organization is an avid bridge builder. Notable among these bridges are 1) An extensive substantial bridge to Weill Cornell Medical School and Cornell Medical Center 2) Bridges to several other medical schools such as Downstate Medical Center, St. George Medical School and Ross Medical School.The presence of all these bridges allowed New York Methodist Hospital, CME Program to have 1) access to a wider pool of educators, 2) a longer cohort of doctors-in-training who get oriented doing their formative years to the significance of CME Programs 3) a better handle at evaluating its CME programs since it enlarges the statistical sample 4) Younger audience are generally more willing to articulated needs and discuss deficiencies, which allows CME another window at identifying needs.

E.6. New York Methodist is part of the Cornell Health Network system. That status has demonstrated certain qualities, skills and facilities as to upgrade the whole institution evaluation of the importance of CME and its role in improving outcome.

E.7. The participation and bridges that New York Methodist have adopted consistently has helped to shape policies in the network it belongs to in such a way as to enhance New York Methodist abilities to satisfy its own mission. The close links between New York Methodist mission and that present CME demonstrates clearly the positive impact of these links of the CME Program.

F. The implementation of changes would impact CME as follows:F.1 Update application form:

Benefit to CME: i. incorporate new accreditation standardsii. stress methods of identification of neediii. monitor planning program and its relevance to

identified needs

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iv. identify various measures of program effectivenessF.2. An end of program survey of attendees using a special survey tool benefit

to CME: Compare and contrast results of this monitoring tool with cumulative results of analysis of evaluation form items.

F.3. Observing and documenting in real time, the rate of success of various physicians in being recertified by their boards. Benefit to CME: highlight the importance of linking programs to performance results. Enhance the importance of CME to physicians continued accreditation.

F.4. Strengthen the position of CME in hospital and medical staff organization hierarchy. Benefit to CME: Enhance the importance of CME mission and its activities in the hospital. The increased visibility of CME will allow it to be a first-hand member of the QI committee of the hospital. Presently, Dr. Rafla is a member of the hospital QI committee by virtue of representation of radiation oncology. We aim at making the director of CME an ex officio member of this committee.

G. Present program was approved on a provisional basis about 2 years. During this period, the following changes were made:

i. Complete computerization of the program developing a verified tool for evaluation, a program to analyze the various components of evaluations, a program to create an institution-wide analysis of CME and its impact on physician improvements.

ii. Changed the application from repeatedly as to underline and highlight important items that must be addressed.

iii. For RSS, we were able to influence program design as to address more clearly needs identified. That step of change was achieved during the process of program fleshing and finalization after the preliminary site application. Many confidential meets were held to verbalize this input.

iv. We focused on monitoring the programs by instituting the program of unannounced site visits, site visit reports and early action on identified deficiencies.

v. We approached hospital administration and medical staff organization to work towards change 4. As a result of that, the electronic information board was instituted in the doctors’ lounge.

H. New York Methodist Hospital organization is result oriented. The impact of improvements described in G is to strengthen the CME program. A full accreditation of the program with commendation is the most solid proof of the worthiness of these changes.

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Cost-benefit of the program is another measure used by hospital management for evaluation of worthiness of the program.

Increased number of physicians who are recertified by their boards is a credible measure of the success of the program.

Increased viability and virtuosity of the medical staff in improving patient outcome, expending scopes of patient, adoption of new knowledge and technology and growth of important patient care programs, are all measures of worthiness of CME.

I. During the last very few years and consistent with CME accreditation, success of the following achieves were claimed by New York Methodist organization:

i. expansion of their cardiology program to include cardiac physiology and all aspects of cardiac care (linked to cardiology CME)

ii. Expansion of neurology, neuro-oncology and neuro-imaging (linked to neruo-oncology CME) The stroke program was also a beneficiary of that.

iii. Expansion of pain management (linked to Pain Management CME program

Many other achievements in nursing, emergency medicine, pediatrics, pulmonary medicine, onco-surgery are linked into the CME program and the continuous vibrant development of its activities.

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IX. Essential Area 3: Engagement with the Environment (Criteria 16 – 22)

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IX. Engagement with the Environment

A. NEW YORK METHODIST HOSPITAL integrates CME into the process of improving professional practice as follows:

2. Incorporating CME credits as an important component of the reaccreditation of physician to practice in the hospital (Enclosure 4)

3. Each department has a standard of physicians attendance to educational activities as part of the continuing system to upgrade and improve medical practice (Enclosure 5)

4. As the hospital is moving towards comprehensive digital conversion of record, activities are planned to enhance these skills, thus improving indicated practice.

B. The most important strategy pursued by NEW YORK METHODIST recently to enhance change is the digitization of information that is now implemented in radiation oncology, pharmacy, nursing and some aspects of OR practice.

Hands on training is the method of choice. Enclosure 6 represents a schedule of such training (Cerner schedule Enclosure 6). These skills are now essential for practice improvement and it affords the physician access to important up-to-date information. Hands on training is also the preferred method for ACLS and BCLS. Enclosure 7 represent that ongoing non-CME activity.

NEW YORK METHODIST has also monitored non-CME activity skills, targeting at improving documentation and enhancing quality of practice - Enclosure 7 – Dr. Silver or Sherbell’s office

C. Along with other health providers, NEW YORK METHODIST has identified several blocks to good patient care that is outside the power of their content such as fragmentation of investigations and resultant waste in necessary testing, problems of access related to present day third party influence, indemnified cost of new and useful technologies. These and other factors that surface through day-to-day practice are used to plan and mount activities, some CME credentialed, such as courses, others became the subject of talks during medical board and social meetings of the medical staff.

D. Educational strategies are utilized by New York Methodist to address barriers to physician changes even at its most basic level e.g legible handwriting for which an activity was planned and carried out by office of medical affairs.

E. NEW YORK METHODIST has positioned itself as a major campus for several medical schools including a. Cornell Medical Schoolb. St. George Medical Schoolc. Ross Medical School

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d. Memorial Sloan Ketteringe. Tulane and Temple Schoolsf. New York College of Podiatric Medicineg. Barry Universityh. New York Institute of Technology

Through that influence, which starts in the formative years of these physicians, NEW YORK METHODIST influences the scope and content of educational intervention.

These teaching efforts are engaged and supported by the Office of Medical Affairs, which is also responsible for the CME unit. (Enclosure 9)

We have also demonstrated through the several organizational tablessubmitted that these activities occupy a prominent role in hospital mission and administrative structure. The latter is fully supported financially by NEW YORK METHODIST funds.

F. CME unit is part of several multidisciplinary activities that enhance physicians, knowledge and performance increasing the potential for improving patient outcome.

The 2 most important multidisciplinary activities are:1) Tumor Board (Physicians in following disciplines,

Oncosurgery, Oncology, Radiation Oncology, Radiology, Social Services) attend. Board activities are CME credentialed.

2) NeuroOncology (Physicians in neurology, neurosurgery, radiation oncology pathology and rehab attend. Program is CME credentialed.

3) Radiation Oncology/Rad/Path (Physicians in radiology, pathology, radiation oncology) weekly meeting. It is CME credentialed.

All these conferences are also attended by audience approved by CME eg, medical students, nurses, physician assistants and technologists.

G. New York Methodist organization has positioned itself strongly to influence scope of content of educational intervention through the following procedures and practices:G.1 Board of Trustees Committee of Professional relations that receives, reviews and approves minutes of all educational activities and report to Board of Trustees.G.2. Office Medical Education: Office is headed by Senior Vice President to whom all departments report on medical education. CME is part of this office.

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G.3. Graduate Medical Education Committee: Chaired by the Senior Vice President of Medical Affairs and attended by leads of all educator leaders of the institute. CME director is a member of this committee.G.4. Medical Education Committee of the Medical Boards, which monitors all the physician medical education activities in the institute. CME committee reports to this committee. Reports of this committee go to Medical Board executive Committee and professional Relations Committee of the Board of Trustees and Board of Trustees.

Through that comprehensive structure, the institute exercises significant leadership in influencing content and conduct of all educational activities.

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X. Administration

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X.A.Organizational Structure: CME unit is part of Medical Affairs Office of NY Methodist Hospital. Office is

headed by Senior Vice Present, Stanley Sherbell, MD. The CME unit is headed by Sameer Rafla, MD, PhD. The coordinator of CME unit is a full-tme staff member chosen by the CME Director. Office is responsible for all medical education.

The CME unit (Director) is chosen by Senior Vice President for Medical Affairs in concurrence with the CME committee and the Medical Education Committee.

CME Director and CME committee choose members of steering committee. CME Director runs CME office and its staff. Chairs and coordinates steering

committee activities. Conducts CME business. Coordinates application for renewals and site visits. Responsible for all administrative steps of program. Reports to Senior Vice President for Medical Affairs and interact with Medical Education Committee.

CME Committee meets every 3 months and receives reports from the director and the steering committee. Upgrades all activities. Reviews budget and need. Evaluates program progress.

Director chairs CME committee. Committee reports to Senior Vice President for Medical Affairs and Medical Education Committee of medical board which in turns reports to the Executive Committee of the Medical Board and Medical Staff. These reports are then submitted to hospital president and board of trustees.

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X.B. Resources available to CME Unit:CME Office: Office is located in conjunction of the CME Director S. Rafla, MD, PhDCME Computerization:Day-to-day computer with adequate terminals and communication links

- Eeds data system- Special computer for scanning and analyzing data

Financial Support:All staff, computerization and coordinators are supported by New York Methodist

The program also receives support from the organization of the Hospital Medical Staff (Medical Board)

X.C. Business and Management ComponentAll CME activities are managed by CME Director and coordinator and responsible for all aspects of management of the unit including

- securing accreditation and reaccreditation- reviewing programs and advising on preliminary applications- reviewing all proposed commercial support and advise on

appropriateness and data completion- receiving final applications, budgets, brochures- receiving all attendance computer records- receiving all evaluation forms and their computerization- generating necessary analysis and reports to various committees

and authorities- running all the business and meetings of the CME committee and

steering committee- obtaining physicians computer generated certificates of credits.- Answering the various queries and questions related to CME

activities- CME employees submit to NEW YORK METHODIST Human

Resources rules and regulations

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Business and Management Practices

1. Employee issues: CME employees submit to all rules and regulations of Human Resource of NY Methodist. Enclosure 48 is the Human Resource employee manual of NY Methodist Hospital.

2. Copy of budget and final income and expenses summary for example CME activity

Enclosure 34 is a copy of budget and final expenses of (Pediatric department).

i. Table of contents of Human Resources Employee Manual:

History of New York Methodist Hospital

Getting Started at New York Methodist HospitalPre-Employment Process, Monday Morning Welcome, Identification Badge, New Employee Orientation,Recording of Time Worked, Pay Day, Employment at Will, Drug-Free Workplace, Physical Examination,Evaluation Period

Employee Guidelines and ProceduresPersonal Appearance, Confidentiality, ComputerUse, Gratuities, Soliciting, Telephones, Cell Phones,Work Schedule, Overtime, Change in Status, Employment of relatives, Reporting Absences FromWork, Performance Evaluation, Determination of Salary, Transfers and Promotions, Equal Employment Opportunity, Sexual Harassment, AccommodationsFor Religious Practices, Accommodation for Disabled Employees, Complaints of Discrimination orHarassment, No Relation for Complaints of Discrimination or Harassment, Staff Rights,Employee Grievance Procedure, Resignations andTerminations, Exit Interviews, Meal time, Breaks

Employee Benefits

Insurance Benefits, Other Benefits, Leave of Absence,Paid Leave, Sick Leave, Workers’ Compensation, Disability, Employee Assistance Program

Safety/Health/ConductFire and Safety, Noise Level, Hazardous Materials,Hospital Disaster and Incident Preparedness, CodePink, Infection Control, MRI safety, Smoking Policy,Security, JCAHO National Patient Safety Goals,Corporate Compliance, Prevention and Reporting

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of Fraud and Abuse

Customer Service StandardsSix Customer Service Standards

Miscellaneous InformationEducation and Training, NEW YORK METHODIST Federal Credit Union, Gift Shop, Cafeteria, Pastoral Care,Publications, Department of Education andVolunteer Resources, Employment of relatives,Theater Development Fund, Employee Discounts,Service Awards, Blood Donation, Inspection of Packages, Personal Mal, Employees on Hospital Premises, Visiting Patients, Witnessing Documents, Visitors

Our Credentials and Institutional Affiliations

Important Phone Numbers

Map

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Business Practices

CME Budget :

Staff:CME Director Voluntary UnpaidS. Rafla, M. D., Ph.D., FACR, FRSM.CME Coordinator $ 30,000.00 *Ms. Jeanine Castellano

Computerization:Hardware $ 15,000.00Software $ 7,000.00 *Supplies As needed

Funds Supplied NY Methodist office of Medical Affairs

Other Income/Yearly: ♦

Contribution of Medical Board of NY Methodist $ 10,000.00Departmental Contributions $ 4,000.00

* Hospital Budget supports these expenses♦ All income is deposited in special fund at New York Methodist

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MSSNY PoliciesAccreditation Statement

The purpose of CME is to enhance the physician’s ability to care for patients. NY Methodist Hospital is applying to be an accredited provider of CME

Standards1. As an accredited provider NEW YORK METHODIST CME will be responsible

for assuring that the content and scientific integrity of all certified CME activities are consistent with the mission of the program.NEW YORK METHODIST CME program shall specifically be responsible for

assuring that:1.1. Activities are scientifically vetted and valid, free of commercial bias and deal

with objective data and information.1.2. Any commercial support shall not control the planning, content or execution of

the activity1.3. The faculty shall control all contents of slides and reference material, which shall

not advance any specific proprietary interest.1.4. No commercial support shall be allowed to dictate, directly or indirectly the

choice of the speakers, invitees, audience or content.1.5. All information about the content of CME activity are the responsibility and

under the control of program committee. Dissemination of these brochures, however, maybe assisted by outside sources (e.g. the Internet).

1.6. If an activity supported by commercial entity is scheduled as a repeated event, each event will be considered individually and must meet the entire “essential” requirement.

An example of accreditation statement follows:The Medical Society of the State of New York (MSSNY) is accredited by the Accreditation Council for CME to provide CME for physicians.New York Methodist Hospital CME Program is accredited by the MSSNY to provide CME for physicians.

New York Methodist Hospital CME Program designates this education activity titled --------------------- for a maximum of ------------ category 1 credits towards the American Medical Association Physician’s Recognition Award. Each physician should claim only these credits that he/she spent in activity.

Disclaimer: New York Methodist Hospital CME is committed to providing educational activities that are objective, balanced and as free of bias as possible. All participating faculty are expected to disclose to the audience, verbally or in writing, any commercial relationships that might be perceived as a real or apparent conflict of interest related to the content of their presentation, i.e. with companies whose product may be referred to during the presentation.

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Special Needs: In accordance with the American with Disabilities Act, NEW YORK METHODIST-CME seeks to make this conference accessible to all. If you have a disability which might requires special accommodations, please contact ……… or e-mail your needs to:

Record Keeping

Application form for a program CME credits activities (enclosure 6). Attendance record – electronically submitted. Participant evaluation – paper and electronic participation evaluation (enclosure

10) Letter of agreement – sample submitted (enclosure 17). Program evaluation and score form (enclosure 11& 12). Speaker disclosure form (enclosure 6) Activity planner disclosure form (enclosure 7& 8). Budget plan form for the activity (enclosure 7 & 8). Commercial support disclosure form (signed by the company and program

director)(enclosure 18). CME steering committee meeting minutes (enclosure 19). CME committee meeting minutes (enclosure 20).

Educational Enduring MaterialsAll CME enduring materials including printed, recorded or computer assisted instructional material shall constitute a planned activity of CME. The development and utilization of these materials shall follow these guidelines:

1. All design and use of enduring materials shall comply with CME mission statement.

2. Enduring materials shall be relevant to the needs of the target group and assuring the satisfaction of activity objectives.

3. Each enduring material used shall have:1. Stated Objective communicated to participants2. Its detailed usage including, study time allocated, overall length of recorded

material and scientifically verified content.3. Enduring material shall be evaluated at least once yearly to assure compliance

with developments in relevant science.4. Findings from audience evaluations shall be used to upgrade the material5. All enduring materials shall have the date of its origination as well as reviews

and updates.4. All the caveats of development and usage of enduring materials applies to jointly

sponsored programs, with the CME program assuming responsibility for all steps of planning (identification of needs, target audience, educational objectives), content, selection of faculty and media as well as quality of production.In addition marketing, dissemination and audience participation shall be part of CME brief.

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In Summary, Enduring materials shall communicate the following information to participants:

1. Needs addressed.2. Specific learning objectives.3. Target audience.4. Educational content.5. Faculty and their credentials.6. Media planned for use.7. Audience participation methods.8. Planned time of the program (equal to designated CME hours).9. Dates of original release, review, and updates.10. Evaluation methods.

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X.G. Mechanism to Retain Activity Records

- All activities records are held in the CME office controlled by CME coordinator

- CME activities attendance computerized records are held by Eeds (Electronic Education Documentation System)

- CME Evaluations forms are held in the CME Office controlled by CME Coordinator

- CME Evaluation computer scanner is kept in CME Office - Computerized CME evaluations and analysis are held by Scantron

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Name Dept., Title Contact Info.1- Baccash,

Emil MD FACP

Pulmonary Medicine Present President of Medical Tel: (718) 780-5110Staff and P.P. Fax: (718) 780-3222

Email: [email protected] Bharathan,

Thayyullathil MD




Fax: (718) 246-8656



Email: [email protected] Gaeta,

Theodore MD MPH

Emergency Medicine Practicing Physician and Tel:(718) 780-5040 - YesmineChairman research committee Fax: (718) 780-3153

Email: [email protected] Lapidus,

Claudia MDRadiology Radiologist Tel:(718) 780-5870




Past President of Medical Staff Email: [email protected] 8- Mir, Rabia

MDPathology Pathologist, Tel:(718) 780-3634



Pediatrics Chairman and Tel:(718) 780-5260


10- Rafla, Sameer MD

Radiation Oncology Chairman and Tel: (718) 780-3677


Rucinski, James, MD General Surgery Deputy program director for Tel: (718) 780-3288

Program of Surgery and P.P. Fax: (718) 780-3154Email: [email protected]

12- Salama, SalamaMD

Pulmonary Medicine Practicing Physician Tel: Fax: (718) 621-7103Email: None (outside)



Email: [email protected] Sherbell,

Stanley MDPulmonary Medicine Executive V.P. for Medical Affairs Tel: (718) 780-3284


15- Int., Medicine Cardiology Cardiology, Past President, Tel: (718) 499-5300 (outside)

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Schifter, David MD

Medical Board, Practicing Physician Fax: (718) 499-6161Email: does not have

16- Simon, Todd MD

Internal Medicine Vice Chairman Dept., of Medicine Tel: (718) 780-5251Fax: (718) 780-3259Email: [email protected]



18-

Yarmush, Joel MD Anesthesiology

Vice Chairman and

Tel: {718) 780-3279



Neuro-surgery Practicing Physician Tel: (718) 246-8610Fax:(718) 246-8611Email: [email protected]

Committee is Chaired by Sameer Rafla, MD, PhD, CME Program Director. Committee minutes become part of Medical Education Committee Minutes → Board of Trustees after Executive Committee reviews

CME Steering Committee Members:

Sameer Rafla, MD. PhD

Chairman Emeritus, Radiation OncologyDirector, CME Program

Stanley Sherbell, MDExecutive Vice President for Medical Affairs

Thayyullathil Bharathan, MDVice Chairman Department of Medicine Associate Program Director

Todd Simon, MDVice Chairman Department of Medicine Associate Program Director

Antonio Mascatello, MDInternist, Department of Medicine

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ENCLOSURES 1. Samples of QI meetings, incident meetings and hospital QI meetings2. Awaiting response from Dr. Silber – organized educational effort 3. Mammosite meeting minutes4. Guidelines for credentialing and recredentialing (Dr. Sherbell’s Office) Pending5. Guidelines from department of surgery about attendance of surgeons of department

educational meetings (Tortalani’s Office) Pending6. List of CERNER training session Pending7. Handwriting skills course8. ACLS & BCLS Pending9. List of medical schools whose students are accepted at New York Methodist10. A sample of minutes of planning committee with highlighted name of CME

Committee Member11. Sample of an application form, activity agreement, disclosure forms, financial

agreement forms, budget, etc. 12. Evaluation Form and items of CME it addresses 13. Analysis of Evaluation14. Site visitor Monitor Form15. Letter to Anesthesiology16. M&M of Surgery17. RT Guest Speaker Program18. Learner Change Data 19. Pre/Post Test reflecting learner change data20. An analysis of evaluations/20B. detailed analysis of programs21. QI Committee report as example22. Minutes of planning committee – Radiation Oncology23. Radiation Therapy Resident Symposium24. Surgery Resident Symposium (Grand Rounds)25. Monitoring of Radiation Therapy26. Monitoring of Surgery27. Resident Symposium Radiation Oncology28. Retreat of Radiation Oncology Minutes29. Standing guidelines for commercial support30. Disclosure Form31. Guidelines for refusal and conflict of interest32. Disclosure statements to audience33. Evidence of hospital knowledge and control of financial support34. Final budget of two examples35. Brochures of two programs to show minimal planned social events36. Examples of written agreement37. Handouts of two resident symposium from Radiotherapy38. Letter of agreement with program directors to show that there is no Conflict of

Interest39. Sickle cell brochure with CME members clearly displayed40. The final statistical report of evaluation41. Evaluation form

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42. Picture of the eeds system43. Report of site visitors to Radiation Oncology and Surgery44. Balance sheet (Final activity budget – RSS and single event conferences)45. Steering Committee Minutes including CME Mission Statement review46. Activity List47. Policy and Procedures of CME

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Name of Activity

Date and TimeLocation of Activity

Speaker/Program Director Name and Title

Objectives:

Accreditation StatementNew York Methodist Hospital is accredited by the Medical Society of the State of New York to provide continuing medical education for physicians

New York Methodist Hospital designates this educational activity for a maximum of XX AMA PRA Category 1 Credit (s) ™. Physician should claim credit commensurate with the extent of their participation in the activity.

Disclosure StatementPolicies and standards of the Medical Society of the State of New York and the Accreditation Council for Continuing Medical Education require that speakers and planners for continuing medical education activities disclose any relevant financial

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relationships they may have with commercial interests whose products, devices or services may be discussed in the content of a CME activity.

Please choose one

The following speakers and planners have no relevant financial relationships to disclose:(insert names of speakers and planners)

The following speakers and planners asked us to disclose information about their financial relationships:(insert names of speakers and planners along with the name of the commercial interest(s) and the nature of the relationship(s)

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CME Self-Study Manual: Report for MSSNY Reaccreditation

Documents

Transcript of CME Self-Study Manual: Report for MSSNY Reaccreditation